The AAMC Nov. 27 submitted comments to the Centers for Medicare and Medicaid Services (CMS) Benefit and Payment Parameters Calendar Year (CY) 2019 proposed rule. The proposed rule would give states the authority to define essential health benefits (EHBs), network adequacy, and essential community providers requirements for qualified health plans offered in the individual and small group marketplaces.
The AAMC is concerned that the proposed changes may limit consumer choice, segment the risk pool, restrict patient access to providers, and leave providers who treat these patients either underpaid or not paid at all. The AAMC urges CMS not to finalize the rule as proposed.
Beginning with the 2019 plan year, CMS proposes to give states greater flexibility in defining their EHB benchmark plan, including the option to redefine the benchmark plan on an annual basis. The AAMC is concerned that this change will allow some states to choose benchmark plans that offer sparse benefit packages. The result will be inadequate coverage to consumers and segment the market, as healthier consumers may choose plans with less robust coverage while those who are sick may choose plans with more robust coverage but significantly higher costs.
In addition to insufficient coverage, premium subsidies tied to benchmark plans will restrict consumers’ ability to purchase high-quality, high-value health plans, because the financial assistance will not be sufficient, particularly for sicker individuals.
CMS is proposing to eliminate the requirements for state-based exchanges on the federal platform to enforce requirements for network adequacy and essential community providers. CMS believes that states are best positioned to determine the standards for the qualified health plan (QHP) certification process for their state. The AAMC cautions that lowering these requirements for QHP certification may limit patient access to needed health care providers, particularly at academic medical centers.
Lastly, CMS proposes to remove the requirements that each exchange have at least two navigator entities and that one of these entities be a community and consumer-focused nonprofit group. The agency is also proposing to eliminate the requirement for the navigator to have a physical presence in the exchange service area. These proposed changes are on top of dramatic funding cuts navigators experienced in advance of the 2018 open enrollment period.
The AAMC urges CMS not to weaken further navigators that provide valuable assistance to consumers who enroll in health plans offered through the exchanges, particularly at a time when choosing a plan in an exchange may become even more complicated.